Benefits Overview 2017 Drug Copayments $10 $25 $45 Medicare HMO Blue (HMO) Medicare HMO Blue (HMO) is a Medicare Advantage plan from Blue Cross and Blue Shield of Massachusetts HMO Blue, Inc. Blue Cross Blue Shield of Massachusetts is an Independent Licensee of the Blue Cross and Blue Shield Association.
Covered Services for Medicare HMO Blue (HMO) Members Plan Specifics In-Network Calendar-Year Deductible $0 Out-of-Pocket Maximum Covered Services Doctor s Office Visits $3,400 calendar-year, out-of-pocket maximum (excludes prescription drug cost-sharing) Your Cost for In-Network Services $15 per primary care provider (PCP) visit $35 per specialty care visit Inpatient Hospital Care Hospital care for illness or chronic disease for as many days as medically necessary (includes hospital care in a rehabilitation hospital) $150 per day days 1-5 Emergency Care 1 Hospital emergency room visits $75 per visit, waived if admitted within 24 hours Urgently Needed Care 1 Doctor s office visit $15 per PCP visit $35 per other provider visit Skilled Nursing Facility (SNF) Care Medically necessary care up to 100 days per $20 per day days 1-20 benefit period 2 $100 per day days 21-44 $0 per day days 45-100 Mental Health and Substance Abuse Outpatient mental health and substance abuse care when medically necessary $35 per visit Inpatient care for mental health and substance abuse $150 per day days 1-5 Annual Physical Exam $0 1. Emergency and Urgently Needed Care are available worldwide. 2. A benefit period begins with the first day of a Medicare-covered inpatient hospital stay and ends with the close of a period of 60 consecutive days during which you were not an inpatient of a hospital or a skilled nursing facility. 1
Covered Services for Medicare HMO Blue (HMO) Members Covered Services Medicare-covered Preventive Care and Screening Tests Your Cost for In-Network Services $0 Mammography screening every 12 months $0 Routine gynecological exam once every 24 months $0 Prostate cancer screening exam once per year $0 Routine Dental Services Routine dental care limited to one initial and periodic oral exam, one cleaning, and one set of bite-wing X-rays every 6 months $35 per visit Hearing Services Routine diagnostic hearing exam once every 12 months Hearing aid, fittings, evaluations, and repairs up to $400 every 36 months $15 per PCP visit $35 per other provider visit All costs over $400 Vision Care Routine refractive eye exam once every 12 months $35 per visit at a Davis Vision network provider Eyewear every 24 months up to a $150 maximum All costs over $150 Other Medicare-Covered Health Services Home health services (non-custodial) $0 Durable medical equipment Prosthetic devices and ostomy supplies Outpatient diagnostic tests and X-rays 10% of the cost (no cost for diabetes equipment and supplies*) 10% of the cost $10 per day for lab tests, X-rays and other diagnostic tests; $150 per day for CT scans, MRIs, PET scans, and nuclear cardiac imaging tests (imaging costs are waived when performed on the same day as an emergency visit or outpatient day surgery) Outpatient radiation therapy $0 * Coverage for diabetic test strips is limited to Johnson and Johnson (OneTouch products) and Roche Diagnostics (Accu-Chek products) when purchased at participating retail and mail-order pharmacies. No coverage for other test strips. For additional information contact Member Service or refer to your Evidence of Coverage. 2
Covered Services Outpatient surgery Physical, occupational, and speech therapy Your Cost for In-Network Services $150 per visit $15 per visit Podiatry Services Medicare-covered services $35 per visit Chiropractic Services Manual manipulation of the spine to correct subluxation $20 per visit Health and Wellness Programs Disease-specific health and wellness education $0 Smoking cessation counseling $0 Health Promotion Programs Eligible health club membership or exercise classes (up to $150 maximum each calendar year) Eligible weight loss program (up to $150 maximum each calendar year) You pay any balance in excess of the $150 limit You pay any balance in excess of the $150 limit Prescription Drug Coverage 3, 4 At a participating retail pharmacy (up to a 30-day supply) 4 Through a participating mail service pharmacy (up to a 90-day supply) $10 for generic drugs $25 for preferred drugs $45 for non-preferred drugs $20 for generic drugs $50 for preferred drugs $90 for non-preferred drugs 3. Prescription drug copayments apply until your out-of-pocket prescription drug costs for covered Part D drugs reach $4,950; thereafter, you will pay $3.30 for generics or drugs treated like generics, $8.25 for all other drugs. 4. Prescription drugs may be available at retail pharmacies up to a 90-day supply. If available, calculate the copayment charge for each 30-day supply. Refer to the Evidence of Coverage for more details. 3
Member Eligibility To enroll in the plan, retirees must permanently reside in the plan service area and be entitled to Medicare Part A and enrolled in Medicare Part B. The service area for this plan includes: Barnstable, Bristol, Essex, Franklin, Hampden, Hampshire, Middlesex, Norfolk, Plymouth, Suffolk, Worcester Counties, MA. You must live in one of these areas to join this plan. In most cases, people with end-stage renal disease (ESRD) cannot enroll in the plan. To locate a participating network provider call the Member Service phone line during regular business hours, or visit Find A Doctor at www.bluecrossma.com. These pages summarize benefits under the Medicare HMO Blue (HMO) plan. Some services may require prior authorization. The benefit information provided herein is a brief summary, not a comprehensive description of benefits. For more information contact the plan. Nondiscrimination Notice Blue Cross Blue Shield of Massachusetts complies with applicable federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex. It does not exclude people or treat them differently because of race, color, national origin, age, disability, sex, sexual orientation or gender identity. Blue Cross Blue Shield of Massachusetts provides: Free aids and services to people with disabilities to communicate effectively with us, such as qualified sign language interpreters and written information in other formats (large print or other formats). Free language services to people whose primary language is not English, such as qualified interpreters and information written in other languages. If you need these services, contact Laureen Corey, Medicare Advantage Appeals and Grievance Manager. If you believe that Blue Cross Blue Shield of Massachusetts has failed to provide these services or discriminated in another way on the basis of race, color, national origin, age, disability, or sex, you can file a grievance with Laureen Corey, Medicare Advantage Appeals and Grievance Manager by mail at P.O. Box 55007, Boston, MA 02205; phone at 1-800-200-4255 (TTY: 711) from February 15 through September 30, 8:00 a.m. to 8:00 p.m., Monday through Friday, or October 1 through February 14, 8:00 a.m. to 8:00 p.m., seven days a week; fax at 617-246-8506; or email at MedicareAdvantageRXAppeals@bcbsma.com. You can file a grievance in person, by mail, fax, email, or you can call 1-800-200-4255 (TTY: 711). If you need help filing a grievance, the Medicare Advantage Appeals and Grievance Manager is available to help you. You can also file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights online at ocrportal.hhs.gov; by mail at U.S. Department of Health and Human Services, 200 Independence Avenue, SW Room 509F, HHH Building Washington, DC 20201; by phone at 1-800-368-1019 or 1-800-537-7697 (TDD). Complaint forms are available at www.hhs.gov. 4
Translation Resources Proficiency of Language Assistance Services English: ATTENTION: If you speak English, language assistance services, free of charge, are available to you. Call 1-800-200-4255 (TTY: 711). Spanish/Español: ATENCIÓN: si habla español, tiene a su disposición servicios gratuitos de asistencia lingüística. Llame al 1-800-200-4255 (TTY: 711). Portuguese/Português: ATENÇÃO: Se fala português, encontram-se disponíveis serviços linguísticos, grátis. Ligue para 1-800-200-4255 (TTY: 711). Chinese/ : 注意 : 如果您使用繁體中文, 您可以免費獲得語言援助服務 請致電 1-800-200-4255 (TTY: 711).. French Creole/Kreyòl Ayisyen: ATANSYON: Si w pale Kreyòl Ayisyen, gen sèvis èd pou lang ki disponib gratis pou ou. Rele 1-800-200-4255 (TTY: 711). Vietnamese/Tiếng Việt: CHÚ Ý: Nếu bạn nói Tiếng Việt, có các dịch vụ hỗ trợ ngôn ngữ miễn phí dành cho bạn. Gọi số 1-800-200-4255 (TTY: 711). Russian/Русский: ВНИМАНИЕ: Если вы говорите на русском языке, то вам доступны бесплатные услуги перевода. Звоните 1-800-200-4255 (телетайп: 711) :ةيبرعلا/ Arabic خدمات المساعدة اللغوية تتوافر لك بالمجان. اتصل برقم 1-800-200-4255 (رقم هاتف الصم والبكم: 711 ).ملحوظة: ا ذا كنت تتحدث اذكر اللغة فا ن Mon-Khmer, Cambodian/ : 1-800-200-4255 (TTY: 711). French/Français: ATTENTION: Si vous parlez français, des services d'aide linguistique vous sont proposés gratuitement. Appelez le 1-800-200-4255 (ATS: 711). Italian/Italiano: ATTENZIONE: In caso la lingua parlata sia l'italiano, sono disponibili servizi di assistenza linguistica gratuiti. Chiamare il numero 1-800-200-4255 (TTY: 711). Korean/ 한국어 : 한국어를사용하시는경우, 언어지원서비스를무료로이용하실수있습니다. 1-800-200-4255 (TTY: 711) 번으로전화해주십시오. Greek/λληνικά: ΠΡΟΣΟΧΗ: Αν μιλάτε ελληνικά, στη διάθεσή σας βρίσκονται υπηρεσίες γλωσσικής υποστήριξης, οι οποίες παρέχονται δωρεάν. Καλέστε 1-800-200-4255 (TTY: 711). Polish/Polski: UWAGA: Jeżeli mówisz po polsku, możesz skorzystać z bezpłatnej pomocy językowej. Zadzwoń pod numer 1-800-200-4255 (TTY: 711). Hindi/ 1-800-200-4255 (TTY: 711) Gujarati/ : 1-800-200-4255 (TTY: 711)
For More Information Current members: please call 1-800-200-4255 (TTY: 711) February 15 through September 30, 8:00 a.m. to 8:00 p.m., Monday through Friday. October 1 through February 14, 8:00 a.m. to 8:00 p.m., seven days a week. Prospective members: please call your employer Visit www.bluecrossma.com/medicare or contact your benefits administrator. Blue Cross and Blue Shield of Massachusetts is an HMO and PPO plan with a Medicare contract. Enrollment in Blue Cross Blue Shield of Massachusetts depends on contract renewal. This information is not a complete description of benefits. Contact the plan for more information. Limitations, copayments, and restrictions may apply. Benefits, formulary, pharmacy network, premium and/or copayments/co-insurance may change on January 1 of each year. Registered Marks of the Blue Cross and Blue Shield Association. 2016 Blue Cross and Blue Shield of Massachusetts, Inc., and Blue Cross and Blue Shield of Massachusetts HMO Blue, Inc. 163284M Grp Rx 10/25/45 Rx 37-0975-17 (11/16)